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<body onload="MM_preloadImages('check22.gif','listofmembers22.gif','newmember22.gif')">
<table width="983" height="694" align="center">
  <tr>
  <td height="137" colspan="4" style="background-color:#666;">
    <div align="left">
      <h1 align="center"><img src="DANlogo.png" alt="logo" width="140" height="140" align="left" /><img src="danHeader2.png" width="705" height="150" /></h1>
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  </tr>
  <tr>
  
    <th width="189" height="540" scope="row"style="background-color:#666;" ><table width="200" height="391">
      <tr>
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      <tr>
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      <tr>
        <th height="107" scope="row"><a href="Untitled-4.php" onmouseout="MM_swapImgRestore()" onmouseover="MM_swapImage('Image4','','newmember22.gif',1)"><img src="newmember1.gif" width="200" height="66" id="Image4" /></a></th>
      </tr>
    </table></th>
    <td width="782" style="background-color:#CCC;"><form action="" method="post" enctype="multipart/form-data" name="form1" id="form1">
      <p>
        <label>Date of incident:</label>
        &nbsp;
        <label for="dateFieldDay"><strong>DD</strong></label>
        <select name="daySelect" id="daySelect">
          <option value="--">--</option>
          <option value="01">01</option>
          <option value="02">02</option>
          <option value="03">03</option>
          <option value="04">04</option>
          <option value="05">05</option>
          <option value="06">06</option>
          <option value="07">07</option>
          <option value="08">08</option>
          <option value="09">09</option>
          <option value="10">10</option>
          <option value="11">11</option>
          <option value="12">12</option>
          <option value="13">13</option>
          <option value="14">14</option>
          <option value="15">15</option>
          <option value="16">16</option>
          <option value="17">17</option>
          <option value="18">18</option>
          <option value="19">19</option>
          <option value="20">20</option>
          <option value="21">21</option>
          <option value="22">22</option>
          <option value="23">23</option>
          <option value="24">24</option>
          <option value="25">25</option>
          <option value="26">26</option>
          <option value="27">27</option>
          <option value="28">28</option>
          <option value="29">29</option>
          <option value="30">30</option>
          <option value="31">31</option>
        </select>
        <label for="dateFieldMonth"><strong>MM</strong></label>
        <label for="monthSelect"></label>
        <select name="monthSelect" id="monthSelect">
          <option value="--">--</option>
          <option value="01">01</option>
          <option value="02">02</option>
          <option value="03">03</option>
          <option value="04">04</option>
          <option value="05">05</option>
          <option value="06">06</option>
          <option value="07">07</option>
          <option value="08">08</option>
          <option value="09">09</option>
          <option value="10">10</option>
          <option value="11">11</option>
          <option value="12">12</option>
        </select>
        <label for="dateFieldYear"><strong>YYYY</strong></label>
        <label for="daySelect"></label>
        <label for="yearSelect"></label>
        <select name="yearSelect" id="yearSelect">
    <option value="--">--</option>
    <option value="2013">2013</option>
    <option value="2012">2012</option>
    <option value="2011">2011</option>
    <option value="2010">2010</option>
    <option value="2009">2009</option>
    <option value="2008">2008</option>
    <option value="2007">2007</option>
    <option value="2006">2006</option>
    <option value="2005">2005</option>
    <option value="2004">2004</option>
    <option value="2003">2003</option>
    <option value="2002">2002</option>
    <option value="2001">2001</option>
    <option value="2000">2000</option>
    <option value="1999">1999</option>
    <option value="1998">1998</option>
    <option value="1997">1997</option>
    <option value="1996">1996</option>
    <option value="1995">1995</option>
    <option value="1994">1994</option>
    <option value="1993">1993</option>
    <option value="1992">1992</option>
    <option value="1991">1991</option>
    <option value="1990">1990</option>
    <option value="1989">1989</option>
    <option value="1988">1988</option>
    <option value="1987">1987</option>
    <option value="1986">1986</option>
    <option value="1985">1985</option>
    <option value="1984">1984</option>
    <option value="1983">1983</option>
    <option value="1982">1982</option>
    <option value="1981">1981</option>
    <option value="1980">1980</option>
    <option value="1979">1979</option>
    <option value="1978">1978</option>
    <option value="1977">1977</option>
    <option value="1976">1976</option>
    <option value="1975">1975</option>
    <option value="1974">1974</option>
    <option value="1973">1973</option>
    <option value="1972">1972</option>
    <option value="1971">1971</option>
    <option value="1970">1970</option>
    <option value="1969">1969</option>
    <option value="1968">1968</option>
    <option value="1967">1967</option>
    <option value="1966">1966</option>
    <option value="1965">1965</option>
    <option value="1964">1964</option>
    <option value="1963">1963</option>
    <option value="1962">1962</option>
    <option value="1961">1961</option>
    <option value="1960">1960</option>
    <option value="1959">1959</option>
    <option value="1958">1958</option>
    <option value="1957">1957</option>
    <option value="1956">1956</option>
    <option value="1955">1955</option>
    <option value="1954">1954</option>
    <option value="1953">1953</option>
    <option value="1952">1952</option>
    <option value="1951">1951</option>
    <option value="1950">1950</option>
    <option value="1949">1949</option>
    <option value="1948">1948</option>
    <option value="1947">1947</option>
    <option value="1946">1946</option>
    <option value="1945">1945</option>
    <option value="1944">1944</option>
    <option value="1943">1943</option>
    <option value="1942">1942</option>
    <option value="1941">1941</option>
    <option value="1940">1940</option>
    <option value="1939">1939</option>
    <option value="1938">1938</option>
    <option value="1937">1937</option>
    <option value="1936">1936</option>
    <option value="1935">1935</option>
    <option value="1934">1934</option>
    <option value="1933">1933</option>
    <option value="1932">1932</option>
    <option value="1931">1931</option>
    <option value="1930">1930</option>
    <option value="1929">1929</option>
    <option value="1928">1928</option>
    <option value="1927">1927</option>
    <option value="1926">1926</option>
    <option value="1925">1925</option>
    <option value="1924">1924</option>
    <option value="1923">1923</option>
    <option value="1922">1922</option>
    <option value="1921">1921</option>
    <option value="1920">1920</option>
    <option value="1919">1919</option>
    <option value="1918">1918</option>
    <option value="1917">1917</option>
    <option value="1916">1916</option>
    <option value="1915">1915</option>
    <option value="1914">1914</option>
    <option value="1913">1913</option>
    <option value="1912">1912</option>
    <option value="1911">1911</option>
    <option value="1910">1910</option>
    <option value="1909">1909</option>
    <option value="1908">1908</option>
    <option value="1907">1907</option>
    <option value="1906">1906</option>
    <option value="1905">1905</option>
    <option value="1904">1904</option>
    <option value="1903">1903</option>
    <option value="1902">1902</option>
    <option value="1901">1901</option>
    <option value="1900">1900</option>
        </select>
      </p>
      <p>
        <label>Time of incident (E.g. 12:45)</label>&nbsp;
        <label for="timeHourSelect"></label>
        <select name="timeHourSelect" id="timeHourSelect">
                    <option value="--">--</option>
          <option value="01">01</option>
          <option value="02">02</option>
          <option value="03">03</option>
          <option value="04">04</option>
          <option value="05">05</option>
          <option value="06">06</option>
          <option value="07">07</option>
          <option value="08">08</option>
          <option value="09">09</option>
          <option value="10">10</option>
          <option value="11">11</option>
          <option value="12">12</option>
        </select>
        <label for="timeField"></label>
        <label> : </label>
        <label for="timeField2"></label>
        <label>          </label>
        <label for="timeMinutesSelect"></label>
        <select name="timeMinutesSelect" id="timeMinutesSelect">
          <option value="--">--</option>
          <option value="01">01</option>
          <option value="02">02</option>
          <option value="03">03</option>
          <option value="04">04</option>
          <option value="05">05</option>
          <option value="06">06</option>
          <option value="07">07</option>
          <option value="08">08</option>
          <option value="09">09</option>
          <option value="10">10</option>
          <option value="11">11</option>
          <option value="12">12</option>
          <option value="13">13</option>
          <option value="14">14</option>
          <option value="15">15</option>
          <option value="16">16</option>
          <option value="17">17</option>
          <option value="18">18</option>
          <option value="19">19</option>
          <option value="20">20</option>
          <option value="21">21</option>
          <option value="22">22</option>
          <option value="23">23</option>
          <option value="24">24</option>
          <option value="25">25</option>
          <option value="26">26</option>
          <option value="27">27</option>
          <option value="28">28</option>
          <option value="29">29</option>
          <option value="30">30</option>
          <option value="31">31</option>
          <option value="32">32</option>
          <option value="33">33</option>
          <option value="34">34</option>
          <option value="35">35</option>
          <option value="36">36</option>
          <option value="37">37</option>
          <option value="38">38</option>
          <option value="39">39</option>
          <option value="40">40</option>
          <option value="41">41</option>
          <option value="42">42</option>
          <option value="43">43</option>
          <option value="44">44</option>
          <option value="45">45</option>
          <option value="46">46</option>
          <option value="47">47</option>
          <option value="48">48</option>
          <option value="49">49</option>
          <option value="50">50</option>
          <option value="51">51</option>
          <option value="52">52</option>
          <option value="53">53</option>
          <option value="54">54</option>
          <option value="55">55</option>
          <option value="56">56</option>
          <option value="57">57</option>
          <option value="58">58</option>
          <option value="59">59</option>
          <option value="60">60</option>

        </select>
        <label>
          <input type="radio" name="timeRadio" value="radio" id="timeRadio_0" />
          <strong>AM</strong></label>
        <label>
          <input type="radio" name="timeRadio" value="radio" id="timeRadio_1" />
          <strong>PM</strong></label>
        <br />
        <br />
      <label>What was attacked?</label>
      <label for="attackedSelect"></label>
      <select name="attackedSelect" id="attackedSelect">
        <option>--</option>
        <option>Wildlife</option>
        <option>Domestic Animal</option>
        <option>Human</option>
        <option>Other (Please specify)</option>
      </select>
      </p>
      <p>
        <label>If other, please provide details:</label>
        <br />
        <label for="attackedOtherText"></label>
        <textarea name="attackedOtherText" id="attackedOtherText" cols="70" rows="3"></textarea>
        &nbsp; </p>
      <p align="left"><label>Place of occurence:</label>&nbsp;
        <label for="occurenceSelect"></label>
        <select name="occurenceSelect" id="occurenceSelect">
          <option>--</option>
          <option>Public footpath</option>
          <option>At home</option>
          <option>On a reserve</option>
          <option>In a vehicle</option>
          <option>Dog park</option>
          <option>Home of friend/family</option>
          <option>Other (Please specify)</option>
        </select>
      </p>
      <p align="left"><label>If other, please provide details:</label>
        <br />
        <textarea name="textarea" id="placeOtherText" cols="70" rows="3"></textarea>
        <br />
        <br />
        <label>Were there any witnesses?</label>
        <label for="witnessesSelect"></label>
        <select name="witnessesSelect" id="witnessesSelect">
          <option>--</option>
          <option>Yes</option>
          <option>No</option>
          <option>Unknown</option>
        </select>
    </p>
      <p><label>If yes, please provide details:</label>
        <br />
        <label for="witnessTextArea"></label>
        <textarea name="witnessTextArea" id="witnessTextArea" cols="70" rows="3"></textarea>
        <br />
    </p>
      <p align="left"><label>Did the injured party know the dog?</label>
        <label for="injuredSelect"></label>
        <select name="injuredSelect" id="injuredSelect">
          <option>--</option>
          <option>Yes</option>
          <option>No</option>
          <option>Unknown</option>
        </select>
      </p>
      <p align="left"><label>if yes, please provide details:</label>&nbsp;<br />
        <label for="partyTextArea"></label>
        <textarea name="partyTextArea" id="partyTextArea" cols="70" rows="3"></textarea>
        <br />
      </p>
      <p><label>What happened? No. of victims, witness statements etc (Attach an A4 sheet if required)</label>
        <br />
        <label for="whatHappenedTextArea"></label>
        <textarea name="whatHappenedTextArea" id="whatHappenedTextArea" cols="70" rows="5"></textarea>
      </p>
      <p><label>Was the attacking dog provoked?</label>
        <label for="provokedSelect"></label>
        <select name="provokedSelect" id="provokedSelect">
          <option>--</option>
          <option>Yes</option>
          <option>No</option>
          <option>Unknown</option>
        </select>
      </p>
      <p><label>Was the attacking dog on a leash?</label>
        <label for="leashSelect"></label>
        <select name="leashSelect" id="leashSelect">
          <option>--</option>
          <option>Yes</option>
          <option>No</option>
          <option>Unknown</option>
        </select>
        <br />
</p>
      <p>        <label>Attach photo evidence:</label> 
        <label for="evidenceFile"></label>
        <input type="file" name="evidenceFile" id="evidenceFile" />
        </p>
      <p>
        <input type="submit" name="submitButton" id="submitButton" value="Submit" />
      </p>
    </form></td>
  </tr>
  <tr></tr>
</table>
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